Robert McNamara, MD, MHSInternational team of Educators Advancing Cardiovascular Health (ITEACH) local the Dominican Republic Society of Cardiology a town near the capital Santo Domingo,
They interviewed 827 adults and found that 1 in 3 individuals with hypertension were unaware of their diagnosis. The survey participants who did know about their high blood pressure were more likely to be older women. They were also more likely to have insurance or had visited a primary care clinic within the past year. Likewise, men, underinsured patients, or those who had not visited a health care center were less likely to be aware of their condition. The research reinforces the need to screen at-risk populations for elevated blood pressure.
The study also uncovered another barrier to blood pressure control. Many patients, even those currently taking antihypertensives, were undertreated. Although the physicians recognized the problem of uncontrolled blood pressure, the rate of medication intensification was only two percent. The data suggest that primary care physicians in that community were reluctant to address the management of high blood pressure with their patients.
“Despite medication availability and affordability, and the majority of patients obtaining their antihypertensives from the primary care clinics, less than half of the patients were prescribed two or more antihypertensives,” the authors wrote.
This phenomenon has been recognized as clinical inertia (CI), defined as the failure of physicians to initiate or intensify antihypertensive therapy despite elevated blood pressure levels not at goal, and is a key factor sustaining the rates of suboptimal therapy. In this study clinical inertia rates were 65 percent. These high rates are not unique to the Dominican Republic. For example, studies show CI to be present in 60 percent of hypertensive visits in the United States, 58 percent of primary care visits in Spain, and up to 88 percent of visits in Brazil and Colombia.
A missed diagnosis of hypertension, lack of training or familiarity with the guidelines for hypertension management, and limited time for patient interactions in the clinic are some of the contributing factors. Clinicians in rural areas may be familiar with the guidelines, but they lacked the confidence to recommend treatment and instead deferred to a cardiologist or nephrologist.
The authors recommended establishing partnerships between the national primary care providers and cardiology and nephrology associations. In addition policy measures that prioritized optimal blood pressure control and regular performance feedback could improve health outcomes.